Tagged "Oral Placement"

Ask A Therapist: Tongue Lateralization

Posted by Deborah Grauzam on

Hi TalkTools,


I completed your training a little over a year ago, but still would like some support when making therapeutic decisions.


I am working with a 12 year old boy who has both language and speech issues (the /r/ and vocalic /r/ phonemes). I just completed a screening and the oral-motor portion of the screening revealed that: a. he could not protrude his tongue straight out of his mouth (it would lateralize), b. his tongue seemed to have a little tremor, c. he had difficulty dissociating his lips/tongue.


I would like to add some Oral Placement Therapy exercises to his therapeutic program. Can you please make some suggestions?


Many thanks,




Hi Wendy,

I have your question and will try to give you some pointer on things to try. If you haven't worked on the Bite Tubes with this client yet, I would if you identify jaw weakness. The jaw is the foundation for everything else to work properly. Next, I feel he probably has tongue weakness and increased weakness on one side based on your report. I would work on tongue lateralization exercises to the Z-Vibe tip and with the Tongue Tip Lateralization & Elevation Tools bilaterally. You will have to work twice on the weaker side depending on what you see with your assessment. You could also work on straws and horns to help with tongue retraction for the /r/ sound.

Please let me know how this goes or email back any other questions.

Thanks so much,



Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 10 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.

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Ask a Therapist: TMJ Sensory Feedback for Calming

Posted by Deborah Grauzam on

Hey Sara,


Recently you had a parent open question meeting in Corpus Christi, TX. I was there with my 8 month old baby. You were talking to a woman who's 5ish son with Down syndrome was repeatedly hitting his chin and you mentioned he was satisfying a feeling that was in his jaw by that action. I have noticed my baby has started doing that with her left hand. What do you recommend to help correct/redirect this behavior now?



Hi L,

The sight of stability and calming for an infant is in the temporomandibular joint. This joint is where the upper and lower jaw meet right below the ear. There are more nerve endings going through that joint than any other location in the human body. When a baby sucks his/her thumb, sucks from a bottle, sucks on a pacifier, etc. the nerves in that joint are stimulated and the baby calms or even falls a sleep. If your child is doing other behaviors to stimulate the jaw like hitting the chin or for older children it may be teeth grinding, then it is probably time to introduce the Bite-Tube Hierarchy. You can learn more about this and other activities to increase jaw skills for both feeding and speech clarity in my book, "Assessment and Treatment of the Jaw: Putting it all together, Sensory Feeding and Speech."

If you do decide to purchase that book please read the chapter on Sensory first as it will explain to you in more detail the reason why babies and children with muscle-based deficits develop "habits" to compensate for the jaw weaknesses. I would also encourage you to share this information with your SLP as she may have additional suggestions.

I hope this has answered your question.

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask a Therapist: Strong Gag Reflex

Posted by Deborah Grauzam on



I am speech pathologist from Finland, took your class about Feeding Therapy: a sensory-motor approach at Helsinki last May. I am sending you an e-mail, because I met a new client shortly after the class and this case really bothers me. I have asked permission from parents, to send this e-mail and pictures/short video when he's eating. So, this boy is 5 years old, he has had feeding issues since he was baby. Nowadays he eats almost anything but no meat. It seems like he doesn't have enough strength at his muscles to bite. When he eats, he puts lots of food into his mouth, only couple of bites and then he swallows. Looks like he's gagging when eating. He uses only couple of words, can't elevate his tongue without gagging. And when pronouncing for example sound /a/, he gags and tongue goes into "cup." He can't reach his upper alveoli with his tongue. The situation is horrible, I have only met him couple of times and it seems like the posterior tongue-tip would be one problem, maybe also tissue around it. I am writing a paper about him because he's going to see a doctor in September. But if it's possible, I would like to get another opinion - yours :-) Thank you so much, if you have time to answer me.




Mrs. R

  IMG_0320 IMG_0343

Hello R,

You are absolutely correct. It looks like he has a type III posterior tongue tie. He probably cannot contract the lateral borders of his tongue. Chewing meat requires much more than just jaw strength, it requires being able to use the lateral borders of the tongue and cheeks together to stabilize the food. That is probably the problem when he is chewing meat. He cannot collect the bolus, and cannot stabilize the bolus on the molar ridge for mastication. He needs to be referred to an otolaryngologist (ENT) or an oral surgeon who understands the correlation between structure and function. Once his frenulum is released you may need to do the lingual exercises for function, BUT you will be able to facilitate the movements he needs for handling more difficult textures. GOOD OBSERVATION!!!!!!

Lori Overland, MS, CCC-SLP, C/NDT

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Ask a Therapist: Stretching the Lingual Frenum

Posted by Deborah Grauzam on

Hi Sara,


The question I had was in regard to the article you have on your website, "Effective Exercises for a Short Frenum” You discuss stretching the frenum by using the Bite-Touch exercise as described in the book Oral-Motor Exercises for Speech Clarity. I have the second edition of the book copyrighted 2001 and cannot find the exercises described.

I was initially confused by this question but in doing further research I realized when I worked on the second edition of that text I changed the name of the exercise from Bite-Touch which I use in my classes to "Tongue Tip Lateralization." Since that time and at the suggestion of Gregory Lof I have changed the name of the book to Oral Placement Therapy for Speech Clarity and Feeding," in the third and fourth editions. Thank you for bringing this to my attention as I will now have to change that information on the online article.

The child I am seeing is 3 years 6 months old. His frenum was clipped a year ago. But there is a remnant of the frenum holding his tongue low in his mouth. His tongue tip cannot reach his alveolar ridge, however he can make acceptable low /s/, dentalized /t/ and /d/ sounds and an acceptable /n/.

This may be true but he is probably using his his jaw to elevate his low position to meet the alveolar ridge during co-articulation. This overuse of the jaw may eventually result in stress to the TMJ and eventually over time can result in TMJ dysfunction.

He can use short 3-4 word sentences fairly clearly, however, His speech becomes more and more unintelligible with longer utterances.

This again may be due to lack of jaw from tongue dissociation and fatigue. Place your tongue at the bottom of your mouth and hold it there while use a few 3-4 word phrases. This lack of tongue from jaw dissociation can result in fatigue and reduction of articulatory accuracy.

He can chew and manage both hard and soft foods. (Eg, pretzel sticks going back on either side of his mouth, chewing gum and moving it from side to side.)

The question here is whether or not he is chewing on his back molars. If not then you will have to identify if that forward placement for chewing on his side teeth is secondary to jaw weakness or to the inability of the tongue tip to place the food on the back molars for "normal" chewing.

His parents have a consultation with the ENT regarding whether a more extensive surgical clip is possible.

I hope the answer is yes as without releasing the tongue tip his issues in speech clarity and feeding safety will continue.

I do not think he is in danger of choking on his food but I do think the limited range of motion may be contributing to the lack of clarity as his sentence length increases. I think he gets fatigued by the effort to use the tongue effectively.

Yes, I agree with that as well.

Thank you for your attention to this. I would appreciate your opinion. I am not sure if stretching will increase the range of motion much but I would try it, if you have found it can make a difference.

The activities entitled "Tongue-Lateralization" and "Tongue Tip Elevation/Depression" are used to stretch the frenum when mobility is a physical option. The stretch is slight as the frenum is not very pliable. We have also developed two tools to assist in the stretch and in developing tongue tip mobility if further surgery is indicated and you need to work on range of motion. They can be purchased on the TalkTools website and come with extensive directions.

I hope this has answered your question.

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask a Therapist: A Therapeutic Alternative to Mouthing Habits

Posted by Deborah Grauzam on

Hi Sara,


It has been awhile since we have seen you in Richmond! James is doing well. His speech seems pretty normal to us at this point (maybe some subtle things remaining). I was emailing with a related question, and hoping that you can point us in the right direction.


James has had some issues in the past with "mouthing" things (for lack of a better word). This seems to wax and wane, but in the last few months, it seems to be significantly worse. He will either have his hands/fingers/thumb in his mouth, or water bottle, pencil, swim cap and goggles, etc depending on the situation. It seems to be something that he does unconsciously, despite our attempts to call his attention to it, even trying "penalties" for having his hands in his mouth. Lately, I have noticed him doing even while talking to his friends, while playing soccer (when there isn't any action near him), etc. He is 11, so it is an increasingly odd behavior than it might have been at age 2. (We haven't noticed any other odd behaviors or habits, just this one...and otherwise he does well in school, socially and in sports).


We aren't sure what the next right step is to help him be able to stop this habit. Deterrents don't seem to work, other than to stop it while it is happening, and I wonder what the root cause of it actually is. I am not sure that a regular speech therapist would be there right person. Do you have any thoughts on how to help him?

The situation you describe is often seen with individuals who have innate muscle weakness. The habits seem to come and go and can take many forms as you mentioned above. Last time I saw him (May 27, 2012) I recommended a gum chewing program. I use gum chewing as outlined in the book Assessment and Treatment of the Jaw for both improving muscle skills in the muscles of the jaw and as an alternative to the "habits" you describe. There are more nerves going through the Temporo-mandibular joint (TMJ) than any other place in the human body. It is where we go for calming. Babies suck their thumbs, bite on their fingers, rely on a pacifier, etc, to give stimulation to that joint.

James may also need to give stimulation to that joint for calming and that is where gum chewing comes into play. If he does not know how to chew gum without swallowing the gum you will have to teach him this motor plan by going to that activity in the book Oral Placement Therapy for Speech Clarity and Feeding. In it you will be given a step-by-step program which I have used with children as young as 2 years of age.

Once​ ​ he can chew independently​ use the gum chewing as an alternative to the "mouthing." I hope this answers your question. Please tell him I said "hello."

Sara Rosenfeld-Johnson, MS, CCC-SLP

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